The World Health Organization was established in 1948 as the
specialized agency of the United Nations responsible for
directing and coordinating authority for international health
matters and public health. One of WHO's constitutional functions
is to provide objective and reliable information and advice in
the field of human health. It fulfils this responsibility in
part through its publication programmes, seeking to help
countries make policies that benefit public health and address
their most pressing public health concerns. The WHO Regional
Office for Europe is one of six regional offices throughout the
world, each with its own programme geared to the particular
health problems of the countries it serves. The European Region
embraces some 880 million people living in an area stretching
from the Arctic Ocean in the north and the Mediterranean Sea in
the south and from the Atlantic Ocean in the west to the Pacific
Ocean in the east. The European programme of WHO supports all
countries in the Region in developing and sustaining their own
health policies, systems and programmes; preventing and
overcoming threats to health; preparing for future health
challenges; and advocating and implementing public health
activities. To ensure the widest possible availability of
authoritative information and guidance on health matters, WHO
secures broad international distribution of its publications and
encourages their translation and and adaptation. By helping to
promote and protect health and prevent and control disease, WHO's
books contribute to achieving the Organization's principal
objective, which is the attainment by all people of the highest
possible level of health. Ever since the WHO European Region
launched its first regional Health for All strategy in 1980, it
has committed itself to making periodic policy updates. These
updates entail regular monitoring, evaluating, rethinking and
revising of how the Region approaches and implements its Health
for All policy. On the one hand, the present update is
mandatory. The WHO Regional Committee for Europe stipulated the
next update of the Region's Health for All policy be submitted in
2005. On the other hand, this obligation is also opportune, or a
good occasion to explore how the function of health systems is
related to ethics and human rights. Moreover, this update gives
us a chance to forge links between established WHO and Health for
All concepts and public health policymaking at the beginning of
the 21st century. The Tenth Standing Committee of the Regional
Committee has been continuously involved in revisiting the
European Region's Health for All policy framework. It has
provided direction on the concept, process and methodology of the
update. It suggested the ethics of the health system be at the
heart of this update and endorsed the core values that underpin
Health for All and Health21, which is the Health for All policy
framework for the WHO European Region, the 1998 update. The
Standing Committee also called for the current update to
acknowledge changing political and economic circumstances and the
growing need to translate values into guidelines and practical
tools, despite the high complexity of such an endeavor. And it
urged elaboration of the concept of ethical governance as a novel
way of linking values to implementation. The Regional Committee
discussed this policy update at two sessions, before and during
its preparation. At the fifty-third session, Member States
agreed the update should ensure continuity with Health21 while
reflecting new knowledge and recent developments, and the core of
the update should emphasize knowledge-based public health
policies and the ethics of health systems. The Regional
Committee also approved the methodology and approach to be taken
by the Regional Office in preparing the update. Member States
were then given a progress report at the fifty-fourth session.
The Regional Office has also regarded the present update as an
opportunity. It initiated the process early to allow ample
collaboration and consultation with Member States. In 2003, when
work began, the Regional Office decided it made sense to develop
the document along three analytical axes. They comprise the
three main pillars of the update, each answering one core
question. The European Observatory on Health Systems and
Policies Responded to this question by conducting a comprehensive
overview of how the Health for All policy has been used in the
European Region. To do so, the Observatory initiated two studies
in 2003. The first study provides a synopsis of the de facto
adoption and use of Health for All concepts in Member States.
The second study, still under way at the time of publication of
this update, assesses countries' experiences with health target
programmes and describes the design and implementation of
national health targets. To assist with the policy-making
decisions, an international think-tank was assembled, consisting
of experts with broad knowledge and experience in formulating,
assessing and implementing health policies internationally,
nationally and sub-nationally. Putting Health for All into
practice offers many challenges. To achieve this goal a review
was conducted of available tools that might enable decision-
makers to construct national Health for All policies and
programmes. A wide range of such tools already exists in many
countries. While they have not been explicitly developed to
implement or assess values, they can be used to do so. From the
tools reviewed, ten main types were chosen to exemplify the
possibilities. The selection was based on whether a given type
had proven useful at a national level, was holistic and
adaptable, had been tested, was undergoing further improvement
and was available. The methodology and the suggested tools are
presented in this report. In addition, they offer policymakers
some guidelines for determining how well their own national
health policies promote Health for All. This update of the
European Health for All policy framework has been developed to be
inspiring rather than prescriptive. It does not provide a model
for Member States to adopt or emulate, but merely offers a
possible architecture for health policy; that is, one based on a
particular vision and values. In developing their own policies,
countries are invited to use this framework in whatever way seems
most useful, adapting it to their specific health, economic,
cultural and historical needs. Ultimately, the true determinant
of success is how an individual country approaches such a
process, and policymakers must decide for themselves which Health
for All elements their national health policy will incorporate.
In other words, the present update is meant to be a framework
that encourages choice. For example, each country must decide
itself whether to allocate specific funds for implementing the
Health for All vision. Where financial resources are limited,
such allocation might be used as a tool to ensure the Health for
All values are respected within the health sector. However, the
adoption of such a financial tool must be country-specific, and a
recommendation cannot be made at the regional level. Another
national choice to make is whether to adopt one single domestic
Health for All policy, or to integrate Health for All into every
existing national policy that has an impact on health, to ensure
that it respects the Health for All values and conforms to the
concept of ethical governance. It is important to emphasize the
present document is only an update of the European Health for All
policy framework, not a new policy. Only seven years have passed
since the adoption of Health21. The Standing Committee of the
Regional Committee felt that, given the relatively short time
that has elapsed, it was premature to develop and propose an
entirely new policy for the Region. Certainly, target-setting
has been a traditional approach in the European Region's Health
for All policy formulation. Recently, however, there has been a
consensus that establishing common targets for all countries in
the Region can often be artificial, unfair or simply uninspiring.
It does not take into account significant differences in Member
States' public health and economic development. Nonetheless,
setting targets can be an important exercise at national and
sometimes sub-national levels. National targets can be an
excellent implementation and guidance tool, as well as a means
for a country to articulate its degree of ambition. And when all
stakeholders are involved, the formulation of national health
targets can help ensure their joint ownership of health policy.
The recommendations included in this update are not exhaustive,
nor do they cover every field of public health. Instead, the
focus is on fields and methods that are either new or have
evolved significantly since 2000. Even though Health21 was
adopted a short time ago, the intervening period has seen many
significant changes in the health systems of Member States. Some
of the experience and knowledge they have acquired is presented
here. In other words, rather than attempting to produce an
authoritative document that finalizes the Region's Health for All
policy, this update aims to encourage an open- ended Health for
All process. The Health for All policy framework can then be
continuously enriched by the broad range of Health for All
activities that individual countries themselves choose to carry
out. Some countries may decide to develop and analyse national
case studies. Other Member States may regard this update as an
invitation to re-examine and revisit their health policies.
Still others might devote special attention to the communications
challenge that involves how best to communicate the Health for
All values, the concept of health and human rights, and the model
of ethical governance to different audiences and stakeholders.
There may also be countries that elect to develop concrete
benchmarks against which to measure the implementation of Health
for All policies. Meanwhile, a given country might focus on the
local level because it sees decentralization and the meeting of
local health needs as essential in successfully implementing
Health for All. In this way, a group of countries could invest
effort in developing national and sub-national health targets and
linking them to the United National Millennium Development Goals.
Most of these ideas were suggested by individual countries during
consultation on the present update. They are only a few among
many possible national activities and developments that could
help give the European Health for All process a new, open-ended
dynamic. The process could serve as a forum for exchanging
up-to-date health policy information, experiences and ideas.
National and sub-national updates could in turn contribute
elements and ideas to the continuing evolution of the regional
Health for All policy, in a permanent process of renewal and
improvement. Such a development would be the best testament to
this document's relevance and usefulness. It is also hoped the
present update will serve as a valuable tool for promoting the
ethical development of health policies. The Health for All
movement in the WHO European Region has been marked by
continuity, and the present update is the latest step in a
cumulative development. Since its adoption in 1998, Health21 has
met with wide acceptance throughout the Region. That framework
update conveyed a broad vision of public health, underpinned by
the core values of the global Health for All movement, and it
outlined the general approach and direction individual countries
might take. It remains valid, and the present update reaffirms
Health21 as the broad policy framework that guides the work of
the Regional Office in its support for Member States. In
particular, the update addresses Health21's call to "provide
up-to-date, evidence-based tools that countries can use to turn
policies on Health for All into action." It reiterates the
significance of the 21 Health21 targets because "they provide a
framework for the Region as a whole, and an inspiration for the
construction of targets at the country and local levels."
Health21 describes its own set of targets by saying they are not
meant to be prescriptive, but together they make up the essence
of the regional policy. The present update maintains this
flexible approach. In short, the current document amplifies
Health21's role as "fundamentally, a charter for social justice,
providing a science-based guide to better health development and
outlining a process that will lead to progressive improvement in
people's health." The present Health for All update is also
consistent with other major health policy formulations. For
instance, the update has been developed in connection with WHO's
Eleventh General Programme of Work, which was carefully prepared
and sought, when adopted in 2006, to outline the main directions
for the Organization's work through 2015. The two documents
share a number of key characteristics, notably a common
foundation in core WHO and Health for All values, a reaffirmation
of the guiding role these values play in WHO work, a particular
focus on the rights and needs of vulnerable populations, and a
flexible approach to national circumstances in the implementation
of policy. This update is also strongly linked to several of the
Regional Office's key policies. In particular, its recognition
of the need for a country-specific approach to health and for
national interpretation and implementation of Region-wide
concepts supports the vision espoused by the Regional Office's
Country Strategy, or "Matching services to new needs." The Health
for All update and the Country Strategy are also united in their
call for developing partnerships outside the health sector.
Moreover, in consonance with the next phase of the Country
Strategy, which is focused on strengthening health systems, this
update places strong emphasis on health systems as the
appropriate setting for national Health for All efforts. The
update is also consistent with the position taken by the Regional
Office on the United Nations MDGs. The values of equity,
solidarity and participation at the centre of the Health for All
update also lie at the heart of the Regional Office's MDG
strategy. These three values are especially significant due to
the economic heterogeneity of the Region, in which poverty
continues to require a great deal of attention not only in low-
and middle-income countries, but also in the richest countries.
These values are highlighted by MDG strategy's emphasis on two
problems; namely, how to achieve the MDGs in countries where they
are unlikely to be met, and how to identify from the national
aggregate data in individual countries the vulnerable
sub-populations the MDGs are most relevant to and then direct
efforts accordingly. The 1946 Constitution of the World Health
Organization states "the health of all peoples is fundamental to
the attainment of peace and security." The Constitution also
recognizes "the enjoyment of the highest attainable standard of
health" as a fundamental human right. By the late 1970s, the
widespread enjoyment of this right was still far from being
achieved, with about one thousand million people in the world
living in such poverty that acceptable standards of health were
quite impossible. Recognizing the challenge, WHO and its Member
States set about creating a special framework to help translate
the vision of universal health into a strategy and policy. The
process began in 1977 with a call for national governments and
WHO to work towards one goal; namely, enabling all the world's
citizens to enjoy by 2000 a level of health that would allow them
to lead a socially active and economically productive life. This
vision and movement have come to be known as Health for All. The
Health for All concept was subsequently introduced at the 1978
International Conference on Primary Health Care in Alma-Ata, the
former USSR. The Declaration of Alma-Ata states that attaining
Health for All as part of overall development starts with primary
health care based on "acceptable methods and technology made
universally accessible to individuals and families in the
community through their full participation and at a cost the
community and the country can afford." Since then, Member States
have been urged to consider the Health for All concept when
formulating policies and action plans. It was believed that, by
interpreting Health for All in a national social, political and
developmental context, each country would be able to contribute
to the global aim of Health for All by the year 2000. The call
for Health for All was, and fundamentally remains, a call for
social justice, equity, and solidarity, and a societal response
that strives for unity in diversity. Rather than enshrining a
single finite goal, Health for All is instead a process of
bringing countries to progressive improvement in the health of
all their citizens. Globally, WHO has continued to pursue its
own commitment to Health for All by adopting in 1981 the Global
Strategy for Health for All by the year 2000 and approving, one
year later, a global action plan for implementing the Strategy.
In 1980, the Regional Committee for Europe approved a European
strategy for attaining Health for All by the year 2000. It
decided to monitor the Strategy's implementation every two years,
beginning in 1983, and to evaluate its effectiveness every six
years, beginning in 1985. Following the initial launch of a
European Health for All policy, the Regional Committee asked for
the formulation of specific regional targets to assist in
implementation of the regional strategy. Such targets were
thought necessary in order to motivate and actively involve
Member States in committing to Health for All. The first Health
for All policy and targets in support of the regional strategy
were adopted in 1984. They provided a broad, but precisely drawn
vision of health development in the Region. They also outlined a
clear ethical framework for policy development. Instead of
focusing solely on inputs to health services, which is
characteristic of an inward-looking, hospital-oriented health
sector, they also emphasized outcomes, encouraging a shift to a
health sector that reaches out and is oriented towards primary
care. In addition, a list of 65 indicators, linked to the
38 regional targets, was devised to measure progress. In the
same year, the Regional Committee also adopted an action plan for
implementing the regional strategy. This framework described the
roles and actions to be taken by the Member States, the Regional
Committee and the Regional Office, respectively. While the plan
was again directly linked to the regional targets, it also left
room for each country to define its own priorities and
strategies. With the adoption of these three documents in 1984,
the Regional Committee created a framework for health policies in
the Region. At the same time, it also established a mechanism to
regularly monitor and evaluate progress towards achieving Health
for All in the Region by 2000. As a consequence of this
commitment, an update of the regional policy, strategy and
targets was made in 1991. Meanwhile, the Regional Committee also
assessed progress towards the regional targets every three years.
In 1998, a revised European Health for All policy framework,
entitled Health21, was adopted. It reflected the extraordinary
changes that had occurred in the Region since the previous
regional policy, including the addition of 20 new pluralistic
societies and their emerging voices, as well as, despite many
positive developments, severe economic downturns that had led to
major crises in the health sector. Health 21 articulates two
primary aims, three basic values and four main strategies. Its
21 targets also provide benchmarks to measure progress in
improving and protecting health and in reducing health risks.
Health for All is and has always been about values, and the
Health for All policy framework links a set of basic values to
the development of health policy. Among them, the core Health
for All value is equity. In the Health for All context, equity
means that everyone has a fair opportunity to attain his or her
full health potential. A concern for equity has direct
implications for how decision-makers choose their priorities in
health policy and for how they decide which public health issues
and which population groups merit the most attention. Health
policies built on concern for equity will ensure health services
are fairly distributed within the population. This could mean
priority is given to the poor and other vulnerable and socially
marginalized groups. Health systems based on equity contribute
to the empowerment and social inclusion of such disadvantaged
groups. Health for All also incorporates the closely linked
value of solidarity, which is usually interpreted as a society's
sense of collective responsibility. In Health for All contexts,
solidarity means everyone contributes to the health system
according to his or her ability. Solidarity can be seen as a way
to ensure equity. A health policy that promotes solidarity is
better able to counterbalance the unequal impact of health
determinants on access to services and health outcomes. In
contrast, a health policy that does not value solidarity will
typically privilege those who are already wealthy, more educated
and more proactive in taking advantage of health-care
entitlements.­ Equity and solidarity are directly linked to a
third value that has become increasingly important in the Health
for All movement, and that is participation. The active
participation of health system stakeholders, including both
individuals and organizations, improves the quality of public
health decision-making. These three values of equity, solidarity
and participation directly affect health-system financing, access
to health services, efforts to improve population health and the
development of high-quality programmes in the sector. They also
affect the dissemination of health information, since the uneven
dissemination of information contributes to inequity and,
conversely, information-sharing is an important tool in combating
it. While there will always be a need to pitch some health
communications to the general population, focus on particular,
individual lifestyle choices and behaviors should not undermine
the importance of public health policies and structural, inter-
sector initiatives. Respect for core societal values, or a lack
thereof, affects such policies and initiatives as much as it does
the population served. In accordance with the Health for All
policy framework, a health policy should address more than just
patient care. Today, this belief appears to be widespread,
especially in countries that have adopted and developed national
Health for All policies. Nevertheless, policymakers throughout
the European Region often find it difficult to incorporate other
elements in their health policies. In several countries, these
policies revolve chiefly around health care. Though the Health
for All framework recognizes the quality of patient care
contributes significantly to a population's health status, it
regards care as only one of many factors in health improvement.
Other major influences include the variety of social and economic
circumstances in which people live and work. There is ample
evidence these structural determinants of population health play
a key role in this rapidly changing Region. That is why the
Health for All framework calls for policymakers to look beyond
health care and recommends a better policy balance among all the
key factors that contribute to population health. In a Health
for All policy, such a balance will be necessarily reflected in
the budget allocations. This plan is in tune with some
countries' efforts to improve the effectiveness of disease-
specific programmes by adopting a more general approach to
strengthening their national health systems. In the Health for
All vision, health improvement is not the exclusive
responsibility of the health sector. There are far too many
examples of how other sectors' policies can lead to an increase
in poor health that the health sector must address. Such
problems can be avoided by involving other sectors in health
improvement. Tobacco, alcohol and nutrition are just three
examples of issues on which it is advantageous for the health
sector to collaborate with other sectors, such as environment,
education, agriculture and industry. Working internationally
enhances efficiency and provides many additional opportunities
for health interventions. For instance, health system
development should be placed high on local, regional and national
development agendas, rather than confined solely to the health
sector as an item of public expenditure. Healthier people have
greater human capital, and therefore, the health sector has
significant potential to impact the overall development and
economic growth of a country. This interaction between health
and other sectors is a two-way process. Non-health
professionals, such as teachers or economists, can also play an
important role in health issues. However, it is important to
remember that such professionals are often just the most visible
elements of other sectors that impact health, so values such as
equity in health need to be linked to the entire structure of
each of these sectors. Health systems are societal institutions
and, as such, their development needs to be based on and driven
by values. For a national health system to be consistent with
the Health for All vision and values, it must have several
important features. There should be enough functioning health
and public health facilities, goods and services to meet the
needs of everyone in the country. Programme capacities should be
similarly sufficient. The determination of what is necessary for
a particular country depends on the national context and level of
development. The need for accessibility applies to every element
of the health sector, but it is particularly critical for primary
care. Access has an economic dimension, which is affordability,
a geographical dimension, which is physical accessibility, an
ethical and human rights dimension, which is accessibility to all
population groups equally, without discrimination, and a
communications dimension, or accessibility of information. All
health facilities, goods and services, including communication
and information, should be culturally appropriate and respectful
of cultural differences and traditions. Mechanisms to ensure the
continuous improvement and upgrading of health services have
become increasingly important to Health for All polices. The
benefits of such changes should be evenly distributed among all
groups, not just available to those who can pay for them.
Quality improvement efforts should focus on how much particular
changes can improve health. For instance, adopting procedures
that ensure patient safety is one efficient way to boost quality.
The benefits of quality improvement include better health,
improved relations between the general public and health
professionals, and a decrease in costly failures in patient
treatment. In Europe, health systems can be described as having
three essential goals; namely, health gain, fairness and
responsiveness. All three are in harmony with the Health for All
concept. Improved health is not only an end in itself, but also
a major factor for overall development, which is another reason
why health gains should be equally distributed among all
population groups. Fairness in financial contributions to health
requires there be sufficient funding to enable universal access
to health services without forcing individuals or families into
poverty. A health system that is driven by Health for All goals
should also respond to non- medical expectations of both
individuals and society; for instance, by safeguarding patient
dignity, confidentiality and autonomy; respecting patient rights;
being sensitive to the specific needs and vulnerabilities of all
population groups; and promoting social inclusion and poverty
reduction. Finally, a health system that respects Health for All
is efficient, by producing the best health outcomes from
available resources. The way a health system works reflects
ethical choices. This plan is true for the four core functions
of a health system; namely, provision of services, finances,
resource generation, and stewardship and governance. Of these,
the biggest challenge to solidarity and equity lies in how a
health system is financed. In a system based on the Health for
All values, budgets should be drawn up to reflect the relative
contributions of the various budget items to health improvement.
For example, a policy that favours sophisticated high-technology
investments should make sure all population groups benefit. The
Health for All concept calls for a broad partnership approach to
health. The Regional Office for Europe works with a range of
international partners, including the Council of Europe, the
World Bank, the European Commission, nongovernmental
organizations and private partners. This cooperation helps
ensure the support the Regional Office provides to individual
countries is consistent with that provided by other public health
stakeholders. Such a collaborative approach also makes better
health outcomes possible by uniting the forces of disparate
partners and setting common agendas, while exploiting each one's
specific strengths and capabilities. With regard to the Health
for All policy framework, such synergy is essential. The
European Region shares certain common societal values, and
respect for these values is seen in the policies and actions of
all international stakeholders. A good example is the work done
within the European Union (EU) system. Through its legal and
financial mechanisms, the EU has achieved a great deal in public
health throughout the WHO European Region. For instance, not
only are environmental standards now enshrined in EU legislation,
they are also automatically applied to countries joining the EU
and used as reference standards by neighbouring countries. In
addition, numerous EU institutions contribute to health-related
activities, such as the European development banks and the
European Commission with their Public Health, Technical
Assistance to the Commonwealth of Independent States and Phare
programmes. In general, EU legislation strengthens the cause of
health in every policy that affects the social and economic
development of its Member States. A common ground of shared
values makes international partnerships for health easier to
sustain. At present, the Health for All concept and values
permeate a variety of the European Region's technical policies;
they also characterize the commitments that Member States have
made before the Regional Committee. It would be a great step
forward for the Region if the major stakeholders in public health
were to enshrine in policy the concept of ethical, values-based
governance. Of the 52 health policies analysed, 40 policies
satisfy all four Health for All criteria that have been
discussed. Nine of the qualifying ones exist only as draft
health policies, although some Member States that are currently
drafting such policies previously had other Health for All
policies in place. Among the twelve Member States without
qualifying policies, two have International health policy
documents that satisfy all the criteria. The Russian Federation
provides a unique example. It has issued a number of Health for
All policy papers focusing on single sectors, most notably health
care delivery.